debra novak, rn, dsn candace m. burns, phd, arnp hhs public...
TRANSCRIPT
Perceived Competence and Comfort in Respiratory Protection:Results of a Nationwide Survey of Occupational Health Nurses
Barbara J. Burgel, RN, COHN-S, PhD, FAAN, Debra Novak, RN, DSN, Candace M. Burns, PhD, ARNP, Annette Byrd, MPH, RN, Holly Carpenter, BSN, RN, MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, Ann Lachat, BSN, RN, COHN-S/CM, FAAOHN, and Deborah Taormina, MS, RN, ANP-BC, COHN-SDr. Burgel is Clinical Professor, Department of Community Health Systems, School of Nursing, University of California San Francisco. Dr. Novak is Senior Science Fellow, National Institute for Occupational Safety and Health–National Personal Protective Technology Laboratory, Pittsburgh, PA. Dr. Burns is Professor, University of South Florida, Tampa, FL. Ms. Byrd is Education Director, American Association of Occupational Health Nurses, Inc., Raleigh, NC. Ms. Carpenter is Senior Staff Specialist, American Nurses Association, Silver Spring, MD. Ms. Gruden is Association of Occupational Health Professionals in Healthcare Community Liaison, Pittsburgh, PA. Ms. Lachat is CEO, American Board for Occupational Health Nurses, Inc., Hinsdale, IL. Ms. Taormina is Nurse Practitioner, Stanford University, Stanford, CA
Abstract
In response to the Institute of Medicine (2011) report Occupational Health Nurses and
Respiratory Protection: Improving Education and Training, a nationwide survey was conducted in
May 2012 to assess occupational health nurses’ educational preparation, roles, responsibilities,
and training needs in respiratory protection. More than 2,000 occupational health nurses
responded; 83% perceived themselves as competent, proficient, or expert in respiratory protection,
reporting moderate comfort with 12 respiratory program elements. If occupational health nurses
had primary responsibility for the respiratory protection program, they were more likely to
perceive higher competence and more comfort in respiratory protection, after controlling for
occupational health nursing experience, highest education, occupational health nursing
certification, industry sector, Association of Occupational Health Professionals in Healthcare
membership, taking a National Institute for Occupational Safety and Health spirometry course in
the prior 5 years, and perceiving a positive safety culture at work. These survey results document
high perceived competence and comfort in respiratory protection. These findings support the
development of targeted educational programs and interprofessional competencies for respiratory
protection.
Occupational health nurses promote and protect worker health and safety in a variety of
industries, ranging from health care to manufacturing, and in small to large employers.
Respiratory protection is a personal protective technology used when engineering controls
Address correspondence to Barbara J. Burgel, RN, COHN-S, PhD, FAAN, Clinical Professor, Department of Community Health Systems, School of Nursing, 2 Koret Way, Box 0608, University of California San Francisco, San Francisco, CA 94143-0608. [email protected].
The authors have disclosed no potential conflicts of interest, financial or otherwise.
HHS Public AccessAuthor manuscriptWorkplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Published in final edited form as:Workplace Health Saf. 2013 March ; 61(3): 103–115. doi:10.3928/21650799-20130218-39.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
are not 100% effective; respiratory protection equipment reduces adverse health outcomes
among workers who may be exposed to hazardous agents ranging from infectious droplets
and aerosols most prominent in the health care industry to dust, fumes, vapors, and
particulates in manufacturing and other industries. Many agencies are involved in workplace
respiratory protection. The federal Occupational Safety and Health Administration (OSHA)
Respiratory Protection Standard 1910.134 outlines the requirements of a respiratory
protection program (RPP) (OSHA, n.d.). The National Institute for Occupational Safety and
Health (NIOSH) certifies respiratory protection equipment, as outlined by the OSHA
standard, and specifies training requirements for conducting pulmonary function tests.
Additionally, the Centers for Disease Control and Prevention (CDC) develops respiratory
protection guidance to prevent communicable diseases. Individual states have additional
respiratory protection safeguards; for example, in 2009 California enacted the Cal-OSHA
Aerosol Transmissible Diseases Standard (Cal-OSHA, 2009).
Consistent and correct use of appropriate respiratory protection by workers at risk has
always been of critical importance. In the past decade, this importance has been highlighted
in the health care sector with epidemics of severe acute respiratory syndrome (SARS) and
novel influenza infections. Barriers to respiratory protection adherence, including discomfort
when wearing respirators (Baig, Knapp, Eagan, & Radonovich, 2010), inconvenience
(Daugherty et al., 2009), and lack of organizational support in health and safety (Nichol et
al., 2008), are reported in the literature. Training to address knowledge gaps has also been
recommended (Daugherty et al., 2009; Lautenbach, Saint, Henderson, & Harris, 2010).
Occupational health nurses are managing RPPs in the workplace and conducting fit testing,
health evaluations, and education programs to protect respiratory health, often in
collaboration with safety, environmental health, industrial hygiene, and occupational
medicine colleagues. However, the scope of occupational health nurses’ role and how
occupational health nurses receive and maintain their knowledge, skills, and abilities in
respiratory protection are unknown.
At the request of NIOSH, the Institute of Medicine (IOM) convened a working committee to
examine occupational health nurses’ competency in respiratory protection. Representatives
from occupational health nursing academic education, continuing education, and practice
presented information regarding respiratory protection education currently provided to
occupational health nurses. The resulting IOM (2011) report, Occupational Health Nurses
and Respiratory Protection: Improving Education and Training, outlined seven
recommendations related to respiratory protection to improve the competency of
occupational health nurses:
1. The American Association of Occupational Health Nurses, Inc. (AAOHN),
working in collaboration with the National Personal Protective Technology
Laboratory (NPPTL) and other agencies and professional organizations, should
conduct a survey of a representative group of occupational health nurses asking
about their current roles and responsibilities relevant to respiratory protection and
for their input on education and training needs.
Burgel et al. Page 2
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
2. Occupational health nurses should achieve and maintain knowledge and skills in
respiratory protection.
3. Nursing education programs at all levels should expand respiratory protection
education and training.
4. Occupational health nurse educators should ensure essential respiratory protection
content is included in occupational health nursing graduate curricula, and should
adapt and apply this knowledge to continuing education programs and the
education and training of all nurses.
5. Occupational health nurses and respiratory protection education programs should
develop, expand, and evaluate innovative teaching methods and resources to
establish best practices.
6. The NPPTL should expand online resources, particularly case studies, relevant to
educating and training occupational health nurses about respiratory protection.
7. The NPPTL should explore the development of respiratory protection core
competencies.
In response to the first recommendation, an advisory group was convened in December 2011
with stakeholder representation from the NPPTL, AAOHN, the American Board for
Occupational Health Nurses, Inc. (ABOHN), the Association of Occupational Health
Professionals in Healthcare (AOHP), and the American Nurses Association (ANA). Two
recommendations guided the initial work of the group; a nationwide survey was conducted
in May and June 2012 to (1) assess current occupational health nurses’ educational
preparation, roles, responsibilities, and training needs in respiratory protection and (2)
determine how occupational health nurses achieve and maintain knowledge and skills in
respiratory protection and motivate employees to use respirators appropriately.
This article reports occupational health nurses’ perceived competence in respiratory
protection and how comfortable occupational health nurses are with 12 required elements of
RPPs. Individual and industry factors associated with competence and comfort are explored,
including the current presence of a work site RPP and occupational health nurses’
responsibility for the program.
BACKGROUND
Little is known about the occupational health nurse’s role in respiratory protection. The IOM
reported that respiratory protection content taught in graduate NIOSH-funded nursing
programs received “varying amounts of dedicated time and resources and (was) taught using
a variety of didactic and practical approaches” (IOM, 2011, p. 2). Outside of these NIOSH-
funded graduate programs, occupational health nurses have a variety of options to access
RPP continuing education. Professional nursing organizations, such as AAOHN and AOHP,
include respiratory protection content in regularly scheduled continuing education
conferences. The 13th edition of AOHP’s (2012) Getting Started: Occupational Health in
the Healthcare Setting identifies respiratory protection for the new occupational health nurse
in the chapter on health and safety. In 2011, the Respiratory Protection in Healthcare
Burgel et al. Page 3
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Settings Web Resource Guide was developed and published by AOHP and the OSHA
Alliance. This guide includes OSHA and NIOSH resources for respiratory protection in
health care settings. The OSHA Alliance has also published a template respirator fit test
card. These items are available through the OSHA Alliance links on both organizations’
websites. The ANA received an educational grant from the National Institute of
Environmental Health Sciences through the International Chemical Workers Union Council
(ICWUC). This grant was used to educate nurses about how to protect themselves in their
roles as hospital-based first receivers of victims after releases of hazardous substances. ANA
and ICWUC provided continuing education and training programs to nurse associations,
hospitals, and schools of nursing through this grant. ABOHN, in its certification
examinations, includes test items on respiratory protection on both the certified occupational
health nurse (COHN) and the certified occupational health nurse specialist (COHN-S)
examinations, and respiratory protection is mentioned as one example of surveillance
programs in the examination blueprint. In the AAOHN (2007) “Competencies in
Occupational and Environmental Health Nursing,” respiratory protection is not specifically
mentioned; however, surveillance program design, implementation, and evaluation, with
training, are captured in Category 3 (Work Force, Workplace, and the Environment),
Category 5 (Management, Business, and Leadership), and Category 7 (Health and Safety
Education and Training). In the third edition of the Core Curriculum for Occupational &
Environmental Health Nursing, a discussion of RPPs is presented (Salazar, 2005).
Additionally, AAOHN Research Priorities (as cited in McCauley, 2012) include exploring
strategies for increasing compliance with or motivating workers to use personal protective
equipment (PPE).
METHODS
A 30-item, web-based survey tool was developed, pilot tested, and revised in February and
March 2012 (Taormina & Burgel, 2013). The survey tool is available on request. A proposal
was submitted to both a university Committee on Human Research and the NIOSH
Committee on Research; this project received a non-research designation. No personal
identifying information was collected from respondents. No information was connected to
individual respondents. In April 2012, the forthcoming survey was advertised via websites
and e-mails to members of AAOHN, AOHP, and ANA and ABOHN-certified nurses. In
May 2012, individual emails were sent to the memberships of AAOHN (n = 5,183) and
AOHP (n = 922), ANA members who identified occupational health as an interest area (n =
249), and ABOHN-certified nurses (n = 4,926). The survey was posted on the web server at
AAOHN and open for approximately 30 days; each sample had more than a 30% response
rate, with 2,263 occupational health nurses responding to the survey.
Five survey items assessed demographic factors, including years of experience, education, if
certified in occupational health nursing, professional organization memberships, and type of
industry. Description of RPP responsibilities (13 items) included if a program was currently
in place, who was responsible, assessment of the need for respiratory protection, if the
occupational health nurse, or others, conducted fit testing, type of respirator used, and
whether a NIOSH spirometry course was completed by the nurse within the prior 5 years.
Five questions assessed how knowledge of respiratory protection was achieved, if the
Burgel et al. Page 4
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Internet was available at the work sites, training preferences, webinar experience, and how
the occupational health nurse motivated workers to use respiratory protection. Two
questions assessed safety culture specific to respiratory protection, and one question
assessed if the occupational health nurse was comfortable explaining the difference between
a surgical mask and a respirator. Two questions focused on current outcome measures used
in this analysis, competency and comfort in respiratory protection, as described below. Two
open-ended questions assessed additional information or education that would strengthen
occupational health nurses’ knowledge of and skills in respiratory protection and if the
respondent had any additional comments to share.
Competency, defined as a sense of mastery of a skill or ability (AAOHN, 2007), was
measured by one item asking occupational health nurses to rate their level of competence in
respiratory protection using Benner’s novice to expert scale; the five answer options were
novice, beginner, competent, proficient, or expert (Benner, 1984). To explore factors
associated with higher competence, these five options were collapsed to two, comparing
competent, proficient, and expert to novice or beginner levels of competence. A 12-item
scale assessed how comfortable the occupational health nurse was with each of 12 RPP
elements; responses ranged from 1, indicating not at all comfortable, to 5, indicating
extremely comfortable. Program elements included, for example, writing a respiratory
protection policy, identifying and assessing potential workplace respiratory hazards, and
performing fit testing. A summative mean score for all 12 items was generated and used to
describe the sample and determine across-group differences. Cronbach’s alpha was 0.92,
signifying very high inter-item scale reliability.
The presence of an RPP at the work site and if the occupational health nurse was primarily
responsible for the program served as the independent variable in the regressions and
included three categories: no RPP at the facility and the occupational health nurse was not
responsible for the program (reference); RPP at the facility but the occupational health nurse
was not primarily responsible; and RPP at the facility and the occupational health nurse was
responsible for the program. Other variables focused on individual factors, including
occupational health nursing experience (in years), highest nursing education (diploma,
associate, any bachelor, any master’s, or doctorate), membership in AAOHN, ANA, or
AOHP (three separate variables with yes/no responses), if certified as a COHN or a COHN-
S (yes/no response), and if a NIOSH spirometry course had been taken in the prior 5 years
(yes/no response). Additional industry factors included employment sector (two highest
proportion industries separately analyzed: manufacturing vs. all others, and health care vs.
all others) and if occupational health nurses perceived their organizations had a culture of
safety related to respiratory protection (yes/no response).
Means, medians, and standard deviations were calculated for continuous variables;
proportions were calculated for categorical variables. Analysis of variance was used to
compare means for significant differences across groups; chi-square was used to compare
proportions for significant differences across groups. Correlations, to determine the direction
of any relationship between variables, were calculated using Pearson’s r for two continuous
variables, Spearman’s rho for categorical variables, and Kendall’s tau for ordinal, ranked
variables. Logistic regression determined which of the multiple factors in the model were
Burgel et al. Page 5
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
significantly associated with higher competence in respiratory protection among the nurse
respondents. Linear regression was used to determine which of the multiple factors were
significantly associated with higher comfort with RPP elements. Individual factors that were
significantly associated with outcomes (p < .10) were included in the multivariate regression
analyses. All analyses were conducted with Predictive Analytics SoftWare (formerly SPSS),
version 18. Significance was set at an alpha of 0.05.
Occupational health nurses’ competence and comfort in respiratory protection were explored
using the following research questions:
1. What is the prevalence of occupational health nurse competence and comfort in
respiratory protection? How are competence and comfort related to each other? Is
knowledge of the difference between a surgical mask and a respirator associated
with competence and comfort?
2. Is occupational health nurse educational preparation associated with higher
competence and comfort in respiratory protection?
3. Which additional individual occupational health nurse factors (e.g., years of
experience, professional organization membership, certification as an occupational
health nurse, NIOSH spirometry course) are associated with higher competence and
comfort?
4. Which industry factors (e.g., presence or absence of an RPP and occupational
health nurse responsibility, industry sector, safety climate) are associated with
higher competence and comfort?
5. On multivariate analyses, which individual and industry factors are associated with
higher competence and comfort in respiratory protection?
Originally, 2,263 AAOHN, ANA, and AOHP members and ABOHN-certified nurses
responded to the survey. For this analysis, 19 were excluded due to missing education data
or because they were not registered nurses. An additional 172 were excluded due to missing
outcome data. A total of 2,072 respondents constituted the sample for this analysis. No
missing value replacement was used.
RESULTS
Prevalence of Competence and Comfort in Respiratory Protection
Occupational health nurses rated their level of overall competence in respiratory protection
as novice (3%), beginner (14%), competent (40%), proficient (35%), and expert (8%); 83%
rated their competence in respiratory protection as competent, proficient, or expert,
compared to 17% as novice or beginner.
Regarding comfort, the mean scores of the summative comfort scale and the 12 RPP
elements are summarized in Table 1. An overall comfort scale of the means of the 12 items
was calculated, with a mean of 3.3 (median = 3.4, SD = 0.92) on a scale of 1 to 5; higher
scores represented more comfort. Conducting health-related evaluations of employee
respiratory fitness had the highest comfort (M = 3.87, SD = 1.09); writing a respiratory
Burgel et al. Page 6
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
protection policy (M = 2.96, SD = 1.23), inspecting, cleaning, and repairing respirator
equipment (M = 3.09, SD = 1.27), and emergency preparedness in relation to respiratory
protection (M = 3.15, SD = 1.24) had the lowest comfort levels.
Competence and mean comfort scores were moderately and significantly correlated
(Spearman’s rho = 0.791, p = .000). Nurses who rated their competence as high (i.e.,
competent, proficient, or expert) had significantly higher mean comfort scale scores (M =
3.57, SD = 0.74 vs. M = 2.08, SD = 0.62) (Table 2).
One item assessed degree of comfort in explaining the difference between surgical masks
and N95 respirators. Twenty-eight percent of the occupational health nurses reported none to
slight comfort in explaining the difference; not surprisingly, this finding was
overrepresented in the novice and beginner levels of competence (rank correlation,
Kendall’s tau-b = 0.476, p = .000) (Table 3). Comfort with RPP elements was additionally
correlated with knowing the difference between a surgical mask and a respirator
(Spearman’s rho = 0.546, p = .000).
Education and Competence and Comfort in Respiratory Protection
Levels of occupational health nurse educational preparation were compared to the five
competence levels and mean comfort scores. Significant differences in perceived
competence in respiratory protection by education are presented in Table 4. The majority of
the occupational health nurses at every educational level perceived their competence in
RPPs as competent or proficient, ranging from a high of 82% of all nurses with an associate
degree to a low of 67% of all those doctorally prepared. Occupational health nurses prepared
at the diploma level were overrepresented in the novice group (15%), occupational health
nurses with a bachelor degree were overrepresented in the beginner group (47%), and
occupational health nurses with any master’s degree or with a doctoral degree were
overrepresented in the expert group.
Table 5 presents the significant differences (p = .000) in mean comfort with RPP elements
by education. Mean comfort scores reflected moderate comfort with all elements of the RPP
(M = 3.3, SD = 0.92, 95% confidence interval [CI] = 3.27–3.35). Occupational health nurses
with any master’s degree had the highest mean comfort scores (M = 3.47, SD = 0.93).
Diploma-prepared occupational health nurses had the lowest mean comfort scores (M =
3.16, SD = 0.91).
Individual Factors and Competence and Comfort in Respiratory Protection
Individual occupational health nurse factors describing the total group are presented in
column 1 of Table 6; two groups were compared to assess significant differences.
Competence in respiratory protection, as compared to beginner and novice, is shown in
column 2 of Table 6; mean values for comfort with RPP elements are shown in column 3.
Occupational health nurses had, on average, 17 years of experience working in the specialty
(range = 0 to 52 years). More experience was significantly associated with higher perceived
competence. Years of experience were significantly correlated with comfort with respiratory
protection (Pearson’s r = 0.151, p = .000). Seventy-three percent of the occupational health
Burgel et al. Page 7
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
nurses were members of AAOHN and 9% were members of ANA; competence and comfort
did not differ by AAOHN or ANA membership. Seventeen percent of the occupational
health nurses were members of AOHP; AOHP membership was significantly associated
with higher competence and comfort in respiratory protection. Seventy percent of the total
sample were either COHN or COHN-S. Being certified as either a COHN or a COHN-S was
significantly associated with higher competence and comfort in respiratory protection.
Thirty-two percent of the occupational health nurses had taken a NIOSH spirometry course
within the prior 5 years; this was significantly associated with higher competence and
comfort in respiratory protection.
Industry Factors and Competence and Comfort in Respiratory Protection
Industry factors are presented in Table 7. Health care and manufacturing were the two
industry sectors most represented by respondents: 35% reported working in health care and
26% reported working in manufacturing. Working in health care was significantly
associated with higher perceived competence and greater comfort in respiratory protection.
Although those working in manufacturing had significantly less comfort with RPP elements,
competence did not differ for occupational health nurses working in manufacturing. Eighty-
eight percent of the respondents reported that their facilities had a current RPP; 50% of the
occupational health nurses reported primary responsibility for these programs. If the
occupational health nurse was not responsible for the RPP, safety was identified as being
primarily responsible (44%), followed by another occupational health nurse or occupational
health nurse manager (18%), industrial hygiene (16%), or environmental health (9%).
Occupational health nurse responsibility for the program was significantly associated with
higher competence and comfort in respiratory protection. Ninety-one percent of the
respondents reported a positive safety culture at the work site for respiratory protection; a
positive safety culture was significantly associated with competence and higher comfort in
respiratory protection.
Logistic Regression Analysis
Factors Associated With Competence in Respiratory Protection—Logistic
regression analysis was conducted exploring respiratory protection competency in
relationship to education, years of experience, AOHP membership, certification status,
NIOSH spirometry course, health care industry, safety climate, presence of an RPP, and
occupational health nurse responsibility for the program (Table 8). This analysis was
conducted with a sample of 1,923 occupational health nurses who had provided complete
data for all factors. If a current RPP was in place and the occupational health nurse was
responsible for this program, the occupational health nurse was 5.8 times as likely to
perceive higher competence, after adjusting for years of experience, highest education,
certification in occupational health nursing, employment in the health care sector, AOHP
membership, taking a NIOSH spirometry course in the prior 5 years, and perceiving a
positive safety culture at work in reference to respiratory protection (adjusted odds ratio
[AOR] = 5.8, 95% CI = 3.8–8.8, p = .000). Years of experience as an occupational health
nurse, certification in occupational health nursing, AOHP membership, working in the
health care sector, taking a spirometry course in the prior 5 years, and perceiving a positive
safety culture at their facilities remained significant in the model.
Burgel et al. Page 8
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Factors Associated With Higher Comfort With RPP Elements—A linear
regression analysis was conducted exploring mean comfort in the 12 RPP elements in
relationship to education, years of experience, AOHP membership, certification status,
NIOSH spirometry course, health care industry, manufacturing industry, safety climate,
presence of an RPP, and occupational health nurse responsibility for the program (Table 9).
This analysis was conducted with a sample of 1,923 occupational health nurses who had
reported complete data for all factors. If a current RPP was in place and the occupational
health nurse was responsible for this program, the mean increase in comfort score was 0.48
on a scale of 1 to 5 (5 indicating extremely comfortable), after adjusting for years of
experience, highest education, certification in occupational health nursing, employment in
health care, employment in manufacturing, AOHP membership, taking a NIOSH spirometry
course in the prior 5 years, and perceiving a positive safety culture at work in reference to
respiratory protection (beta coefficient = 0.478, 95% CI = 0.340–0.615, p = .000). Years of
experience as an occupational health nurse, certification in occupational health nursing,
AOHP membership, working in health care, and taking a spirometry course in the prior 5
years remained significant in the model. Perceiving a positive safety culture and
employment in manufacturing were not significant in the final multivariate analysis. In
contrast to greater perceived competence, education, specifically any master’s degree when
compared to diploma, was significantly associated with higher comfort scores (beta
coefficient = 0.27, 95% CI = 0.13–0.41, p = .000).
DISCUSSION
More than 2,000 occupational health nurses participated in this survey on respiratory
protection, the first survey of its kind. The sample surveyed consisted of highly experienced
occupational health nurses (an average of 17 years of occupational health nursing
experience) with a high perceived competency in respiratory protection; 83% perceived
themselves to be competent, proficient, or expert in respiratory protection. The respondents
reported feeling moderately comfortable with 12 elements of RPPs, perceiving greatest
comfort with health-related evaluation of employees regarding respiratory fitness and least
comfort with writing a respiratory protection policy, inspecting, cleaning, and repairing
respirator equipment, and respiratory protection in the context of emergency preparedness.
Perceived competence and comfort were significantly associated with occupational health
nurse experience in all analyses.
The highest proportion of respondents were baccalaureate-prepared, and 70% were
baccalaureate-prepared and above. These educational data are similar to those from the
recent AAOHN Member Survey; 68% of AAOHN members are prepared at or above the
baccalaureate level (Burgel & Kennerly, 2012). Education was significantly associated with
higher competence and greater comfort in respiratory protection in specific ways. Master’s
education, compared to diploma, was associated with greater competence and comfort.
Although highest educational preparation was not significantly associated with competence
in the final analysis, it did continue to be a significant factor associated with greater comfort
with RPP elements. As a specific educational strategy, completing a NIOSH spirometry
course within the prior 5 years was associated with greater competence and comfort in all
analyses. As one specific knowledge gap, 28.5% of respondents reported none to slight
Burgel et al. Page 9
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
comfort and 21% reported moderate comfort in explaining the difference between a surgical
mask and an N95 respirator. A future article will describe ways occupational health nurses
achieved their competence in respiratory protection, including on-the-job training and
attending professional conferences. Respondents’ preferred methods of learning, and ways
occupational health nurses motivate respirator use, will also be discussed.
Competence and comfort were significantly associated with certification as a COHN or a
COHN-S. Based on AAOHN competencies, ABOHN certification, which requires
experience in the field, continuing or professional education in the specialty, and
successfully passing a norm-based examination, does recognize occupational health nurses
at the proficient level. However, it is not possible to determine, due to the cross-sectional
nature of this survey, if competence in respiratory protection would drive an occupational
health nurse to become certified or if certification drives competence. Continuing education
and current experience in the specialty are required to maintain board certification, adding
support to the notion that board certification drives greater perceived competence.
AOHP membership and working in the health care industry were associated with
competence and greater comfort; employment in the health care industry had the greater
impact. This competence could reflect immersion in RPPs, with engagement in the recent
national debates regarding surgical masks versus N95 particulate respirators for protection
against novel influenza transmission.
Not surprisingly, the presence of an RPP for which the occupational health nurse was
primarily responsible was associated with higher perceived competence and comfort; the
highest impact existed for the presence of both factors. The federal OSHA Respiratory
Protection Standard requires in 1910.134 (c) that “the program must be administered by a
suitably trained program administrator” (OSHA, n.d.). These findings suggest that primary
responsibility either builds higher competence and comfort in the RPP or the perception of
competence and comfort stimulates the assignment of responsibility. These findings lend
support to the conclusion that active and current engagement and primary responsibility for
an RPP are powerful factors contributing to higher perceived competence and comfort in
respiratory protection. Although not fully explored in this study, the involvement of other
team members in RPPs was also evident and deserves further study, including the roles of
safety, industrial hygiene, and environmental health professionals. A perception of a positive
safety culture at work including respiratory protection was associated with higher
competence in the final model but not higher comfort with RPP elements. Another possible
interpretation could be that occupational health nurses with higher competence were more
likely to perceive, create, and enforce a positive safety culture at their work site. Safety
culture and safety climate are important organizational factors as sociated with greater
adherence to respiratory protection (Nichol et al., 2008).
These data demonstrate a high level of competence and comfort in respiratory protection in
this highly experienced group of occupational health nurses, but also highlight some
learning needs. Respiratory protection policy development, inspecting, cleaning, and
repairing respiratory equipment, and respiratory protection in emergency preparedness all
ranked lowest in comfort; 28.5% of respondents reported none to slight comfort in
Burgel et al. Page 10
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
explaining the difference between a surgical mask and an N95 respirator. A need for
ongoing training in respiratory protection is echoed by several recent studies, specifically in
the health care sector. On comparing the findings of this study to findings in the literature,
noteworthy trends are apparent. In a study of critical care health care workers in two
Baltimore hospitals, 40% reported poor adherence in wearing PPE to protect against
influenza and 53% observed that coworkers were non-adherent to PPE use. Only 63% of
respondents correctly identified needed influenza PPE. Akin to these findings,
organizational interventions aimed at improving a culture of safety and targeted respiratory
protection education for health care workers were recommended (Daugherty et al., 2009).
A study exploring factors associated with nurses’ adherence to respiratory protection in two
Canadian acute care hospitals demonstrated that organizational support for health and safety
was significantly associated with greater adherence to personal protection. Organizational
support was defined as “making health and safety a high priority, taking all reasonable steps
to minimize hazards, encouraging employees’ involvement in health and safety matters, and
actively working to protect employees” (Nichol et al., 2008, p. 486).
STRENGTHS AND LIMITATIONS
This was a large survey of four subsets of occupational health nurses in the United States, all
of whom could be identified as professionally affiliated either through membership in
AAOHN, ANA, or AOHP or certification by ABOHN. These data may not reflect the
broader occupational health nurse community and may only be generalizable to experienced
occupational health nurses who are professionally affiliated through either membership or
certification.
Because this was a cross-sectional survey, it is not possible to determine if competence and
comfort in respiratory protection stimulated certification, for example, or if certification, and
maintenance of certification, are driving competence and comfort in respiratory protection.
It is also not possible to determine if membership in professional organizations (e.g., AOHP)
or employment in the health care industry preceded comfort with respiratory protection, or if
those occupational health nurses who are more comfortable with all elements of respiratory
protection are seeking employment in health care settings and membership in AOHP. Most
likely it is a combination of factors or some other unmeasured professional attribute
associated with these factors driving either perceived competence in respiratory protection
or comfort in ad dressing the elements of an RPP.
Additionally, competence and comfort were measured by self-perceptions in this study. How
perceptions link to actual competence in respiratory protection is unknown. Development of
objective measurements of competency in respiratory protection would be a preferred
outcome in future research on this important topic.
IMPLICATIONS FOR PRACTICE
More than 80% of the occupational health nurses sampled reported being competent,
proficient, or expert in respiratory protection, and, on average, occupational health nurses
were moderately comfortable with the 12 RPP elements. Occupational health nurses
Burgel et al. Page 11
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
reported greater comfort in conducting health-related evaluations for respiratory fitness, and
less comfort in inspecting, cleaning, and repairing respirator equipment and emergency
preparedness. The most powerful factor associated with higher perceived competence and
greater comfort was the occupational health nurses’ being primarily responsible for the RPP
at their facility. Years of occupational health nursing experience, occupational health
nursing certification, employment in health care, AOHP membership, keeping current in the
NIOSH spirometry course, and a positive safety culture at work were additional factors
contributing to RPP competence. Years of occupational health nursing experience, master’s
education, occupational health nursing certification, employment in health care, AOHP
membership, and keeping current in the NIOSH spirometry course were additional factors
contributing to greater comfort in the 12 RPP elements. Ways occupational health nurses
achieved and maintained their RPP competence and preferred methods of learning will be
presented in a future article.
CONCLUSION
These survey results document extensive involvement of occupational health nurses in RPPs
at work sites, and high perceived respiratory protection competence and comfort. These
findings provide a baseline to trend future gains in competence and comfort in respiratory
protection. Additional data analyses continue. Future work will include developing targeted
educational programs to address respiratory protection knowledge gaps as evidenced by the
survey findings. In addition, innovative instructional methods will be used to augment the
education of occupational health nurses about all aspects of an RPP, including ways for
occupational health nurses to motivate adherence to respiratory protection. Future IOM
goals include educating all levels of nurses about respiratory protection and developing
interprofessional core competencies in respiratory protection for occupational health and
safety education.
Acknowledgments
The authors thank Patty Quinlan, MPH, Industrial Hygienist, who consulted on survey development.
References
American Association of Occupational Health Nurses Inc. Competencies in occupational and environmental health nursing. AAOHN Journal. 2007; 55(11):442–447. [PubMed: 18019767]
Association of Occupational Health Professionals in Healthcare. Getting started: Occupational health in the healthcare setting. 13th. Wexford, PA: Author; 2012.
Baig AS, Knapp C, Eagan AE, Radonovich LJ. Health care workers’ views about respirator use and features that should be included in the next generation of respirators. American Journal of Infection Control. 2010; 38(1):18–25. [PubMed: 20036443]
Benner, P. From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley; 1984.
Burgel BJ, Kennerly S. Snapshot of the AAOHN membership. Workplace Health & Safety. 2012; 60(11):465–469. [PubMed: 23413480]
Cal-OSHA. Aerosol Transmissible Diseases Standard. CCR, Title 8, Section 5199. 2009. Retrieved from www.dir.ca.gov/title8/5199.html
Burgel et al. Page 12
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Daugherty EL, Perl TM, Needham DM, Rubinson L, Bilder-back A, Rand CS. The use of personal protective equipment for control of influenza among critical care clinicians: A survey study. Critical Care Medicine. 2009; 37(4):1210–1216. [PubMed: 19242326]
Institute of Medicine. Occupational health nurses and respiratory protection: Improving education and training (Letter Report). Washington, DC: National Academy of Sciences; 2011.
Lautenbach E, Saint S, Henderson DK, Harris AD. Initial response of health care institutions to emergence of H1N1 influenza: Experiences, obstacles, and perceived future needs. Clinical Infectious Diseases. 2010; 50(4):523–527. [PubMed: 20064038]
McCauley LA. Research to practice in occupational health nursing. Workplace Health & Safety. 2012; 60(4):183–189. [PubMed: 22432784]
Nichol K, Bigelow P, O’Brien-Pallas L, McGeer A, Manno M, Holness DL. The individual, environmental, and organizational factors that influence nurses’ use of facial protection to prevent occupational transmission of communicable respiratory illness in acute care hospitals. American Journal of Infection Control. 2008; 36(7):481–487. [PubMed: 18786451]
Occupational Safety and Health Administration. 29 CFR 1910.134: Occupational safety and health standards, personal protective equipment, respiratory protection. (n.d.)Retrieved from www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=12716&p_table=standards
Salazar, MK., editor. Core curriculum for occupational & environmental health nursing. 3rd. Philadelphia, PA: Elsevier; 2005.
Taormina D, Burgel BJ. Development of a respiratory protection survey instrument for occupational health nurses: An educational project. Workplace Health & Safety. 2013; 61(2):79–83.10.3928/21650799-20130129-95 [PubMed: 23380641]
Burgel et al. Page 13
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Applying Research to Practice
Occupational health nurses’ responsibility for a respiratory protection program was
associated with greater comfort in 12 respiratory protection program elements and higher
perceived competence in respiratory protection. Occupational health nursing experience,
master’s education, certification as an occupational health nurse, professional
membership in the Association of Occupational Health Professionals in Healthcare,
working in health care, having taken a National Institute for Occupational Safety and
Health spirometry course in the prior 5 years, and perceiving a positive safety culture
were all important factors contributing to greater comfort or higher perceived
competence in respiratory protection. Knowledge gaps existed, however; 28.5% of the
occupational health nurses who responded to the survey reported no to little comfort in
explaining the difference between a surgical mask and an N95 respirator.
Burgel et al. Page 14
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Burgel et al. Page 15
Tab
le 1
Com
fort
With
Ele
men
ts o
f R
espi
rato
ry P
rote
ctio
n Pr
ogra
ms
(n =
2,0
72)
Ele
men
tV
alid
Mis
sing
MM
edia
nSD
Mea
n co
mfo
rt s
core
a in
RPP
2,07
2 0
3.31
353.
4167
0.91
639
Wri
ting
a re
spir
ator
y pr
otec
tion
polic
y?2,
066
62.
9618
3.00
001.
2291
8
Iden
tifyi
ng a
nd a
sses
sing
pot
entia
l res
pira
tory
haz
ards
that
may
be
enco
unte
red
in th
e w
orkp
lace
?2,
064
83.
2398
3.00
001.
0623
5
Und
erst
andi
ng h
ow e
ngin
eeri
ng c
ontr
ols
and
wor
k pr
actic
es a
re d
esig
ned
and
eval
uate
d to
ens
ure
empl
oyee
exp
osur
es a
re li
mite
d?2,
067
53.
2985
3.00
001.
0882
7
Prop
er s
elec
tion
of a
ppro
pria
te r
espi
rato
ry p
rote
ctio
n eq
uipm
ent?
2,06
7 5
3.21
583.
0000
1.14
398
Tra
inin
g em
ploy
ees?
2,06
012
3.48
594.
0000
1.20
114
Insp
ectin
g, c
lean
ing,
and
rep
airi
ng r
espi
rato
ry e
quip
men
t?2,
051
213.
0946
3.00
001.
2725
3
Eva
luat
ing
prog
ram
by
asse
ssin
g em
ploy
ee v
iew
s on
pro
gram
eff
ectiv
enes
s?2,
055
173.
2516
3.00
001.
1399
0
Hea
lth-r
elat
ed e
valu
atio
n of
em
ploy
ees
rega
rdin
g re
spir
ator
y fi
tnes
s?2,
063
93.
8730
4.00
001.
0884
1
Perf
orm
ing
a fi
t tes
t?2,
052
203.
4288
4.00
001.
4365
5
Tea
chin
g re
com
men
ded
user
sea
l che
ck m
etho
d?2,
045
273.
4675
4.00
001.
3934
9
Spir
omet
ry te
stin
g?2,
043
293.
3284
4.00
001.
5039
3
Em
erge
ncy
prep
ared
ness
trai
ning
(re
spir
ator
y pr
otec
tion)
?2,
048
243.
1479
3.00
001.
2413
2
Not
e. R
PP =
res
pira
tory
pro
tect
ion
prog
ram
.
a Cal
cula
ted
by s
umm
ing
mea
ns o
f 12
RPP
ele
men
ts. L
evel
s of
com
fort
with
eac
h of
the
12 e
lem
ents
of
an R
PP w
ere
asse
ssed
on
a 1
to 5
sca
le, w
ith 1
indi
catin
g no
t at a
ll co
mfo
rtab
le, 2
indi
catin
g sl
ight
co
mfo
rt, 3
indi
catin
g m
oder
ate
com
fort
, 4 in
dica
ting
very
com
fort
able
, and
5 in
dica
ting
extr
emel
y co
mfo
rtab
le. H
ighe
r sc
ores
indi
cate
d m
ore
com
fort
.
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Burgel et al. Page 16
Table 2
Associations Between Level of Comfort With 12 Elements of Respiratory Protection Programs and Perceived
Levels of Competence (n = 2,072)
Comfort With 12 RPP ElementsTotal
(n = 2,072)Competent, Proficient, or Expert
(n = 1,712; 82.6%)Beginner or Novice
(n = 360; 17.4%) p
Mean (SD) 3.31 (0.92) 3.57 (0.74) 2.08 (0.62) .000
Median 3.42 3.58 2.08
Range 1–5 1.2–5 1–4.75
Note. RPP = respiratory protection program. Levels of comfort with each of the 12 elements of an RPP were assessed on a 1 to 5 scale, with 1 indicating not at all comfortable, 2 indicating slight comfort, 3 indicating moderate comfort, 4 indicating very comfortable, and 5 indicating extremely comfortable. Higher scores indicated more comfort.
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Burgel et al. Page 17
Tab
le 3
Com
fort
With
Exp
lain
ing
the
Dif
fere
nce
Bet
wee
n a
Surg
ical
Mas
k an
d an
N95
Res
pira
tor
by L
evel
of
Com
pete
nce
(n =
2,0
54)
Lev
el o
f C
omfo
rt W
ith E
xpla
inin
g th
e D
iffe
renc
e B
etw
een
a Su
rgic
al M
ask
and
an N
95 R
espi
rato
r
Lev
el o
f C
ompe
tenc
e
Nov
ice
Beg
inne
rC
ompe
tent
Pro
fici
ent
Exp
ert
Tot
al
Plea
se s
elec
t one
:
N
ot a
t all
Cou
nt44
9612
166
733
4
% w
ithin
leve
ls o
f co
mpe
tenc
e65
.733
.314
.99.
14.
416
.3
Sl
ight
com
fort
Cou
nt17
8111
733
024
8
% w
ithin
leve
ls o
f co
mpe
tenc
e25
.428
.114
.44.
50.
012
.1
M
oder
ate
com
fort
Cou
nt5
7824
110
49
437
% w
ithin
leve
ls o
f co
mpe
tenc
e7.
527
.129
.614
.35.
721
.3
V
ery
com
fort
able
Cou
nt1
2925
827
720
585
% w
ithin
leve
ls o
f co
mpe
tenc
e1.
510
.131
.738
.112
.628
.5
E
xtre
mel
y co
mfo
rtab
le
Cou
nt0
476
247
123
450
% w
ithin
leve
ls o
f co
mpe
tenc
e0.
01.
49.
334
.077
.421
.9
Tot
al
C
ount
6728
881
372
715
92,
054
%
with
in le
vels
of
com
pete
nce
100.
010
0.0
100.
010
0.0
100.
010
0.0
Not
e. C
hi-s
quar
e, p
= .0
00. R
ank
corr
elat
ion
of o
rdin
al v
aria
bles
: Ken
dall’
s ta
u-b
= 0
.476
, p =
.000
.
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Burgel et al. Page 18
Tab
le 4
Hig
hest
Occ
upat
iona
l Hea
lth N
ursi
ng E
duca
tion
and
Perc
eive
d L
evel
of
Com
pete
nce
in R
espi
rato
ry P
rote
ctio
n (n
= 2
,072
)
Edu
catio
n
Lev
el o
f C
ompe
tenc
e
Nov
ice
Beg
inne
rC
ompe
tent
Pro
fici
ent
Exp
ert
Tot
al
Dip
lom
a
C
ount
1038
111
6513
237
%
with
in d
iplo
ma
4.2
16.0
46.8
27.4
5.5
100.
0
%
with
in le
vel o
f co
mpe
tenc
e14
.713
.013
.58.
98.
111
.4
Ass
ocia
te
C
ount
1243
159
149
1237
5
%
with
in a
ssoc
iate
3.2
11.5
42.4
39.7
3.2
100.
0
%
with
in le
vel o
f co
mpe
tenc
e17
.614
.719
.420
.47.
518
.1
BA
/BSN
C
ount
2613
832
931
255
860
%
with
in B
A/B
SN3.
016
.038
.336
.36.
410
0.0
%
with
in le
vel o
f co
mpe
tenc
e38
.247
.340
.142
.734
.241
.5
Any
mas
ter’
s
C
ount
1965
204
192
7555
5
%
with
in a
ny m
aste
r’s
3.4
11.7
36.8
34.6
13.5
100.
0
%
with
in le
vel o
f co
mpe
tenc
e27
.922
.324
.926
.346
.626
.8
Any
doc
tora
te
C
ount
18
1713
645
%
with
in a
ny d
octo
rate
2.2
17.8
37.8
28.9
13.3
100.
0
%
with
in le
vel o
f co
mpe
tenc
e1.
52.
72.
11.
83.
72.
2
Tot
al
C
ount
6829
282
073
116
12,
072
%
of
tota
l3.
314
.139
.635
.37.
810
0.0
Not
e. B
A =
bac
helo
r of
art
s; B
SN =
bac
helo
r of
sci
ence
in n
ursi
ng. K
enda
ll’s
tau-
b =
0.0
71, p
= .0
00.
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Burgel et al. Page 19
Tab
le 5
Com
fort
Sca
le S
core
s in
Res
pira
tory
Pro
tect
ion
Prog
ram
Ele
men
ts b
y L
evel
of
Occ
upat
iona
l Hea
lth N
urse
Edu
catio
n (n
= 2
,072
)
Edu
catio
nN
MSD
95%
Con
fide
nce
Inte
rval
for
M
Low
er B
ound
Upp
er B
ound
Dip
lom
a23
73.
1645
0.90
660
3.04
853.
2805
Ass
ocia
te37
53.
2897
0.89
606
3.19
873.
3807
Any
BA
/BSN
860
3.26
510.
9087
23.
2043
3.32
59
Any
mas
ter’
s55
53.
4686
0.92
752
3.39
123.
5459
Any
doc
tora
te45
3.31
180.
9309
43.
0321
3.59
15
Tot
al2,
072
3.31
350.
9163
93.
2741
3.35
30
Not
e. B
A =
bac
helo
r of
art
s; B
SN =
bac
helo
r of
sci
ence
in n
ursi
ng. C
omfo
rt s
cale
sco
re c
alcu
late
d by
sum
min
g m
ean
scor
es o
f 12
res
pira
tory
pro
tect
ion
prog
ram
ele
men
ts, r
angi
ng f
rom
a lo
w o
f 1,
in
dica
ting
not a
t all
com
fort
able
, to
5, in
dica
ting
very
com
fort
able
(p
= .0
00).
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Burgel et al. Page 20
Table 6
Individual Factors by Competence and Comfort in Respiratory Protection Programs
Individual FactorTotal
(n = 2,072)Competent, Proficient, or Expert
(n = 1,712; 82.6%)
Mean Comfort With 12 RPP Elements
(n = 2,072; 100%)
Years of occupational health nursing experience ;(n = 1,923)
Mean (SD) 16.7 (9.0) 17.3 (8.8)a
Median 16 17
Range 0–52n (%)
0–52n (%)
M (SD)
AAOHN membership
Yes 1,518 (73.3) 1,243 (72.6) 3.29 (0.92)
No 554 (26.7) 469 (27.4) 3.36 (0.90)
AOHP membership
Yes 347 (16.7) 317 (18.5)a 3.57 (0.77)b
No 1,725 (83.3) 1,395 (81.5) 3.26 (0.93)
ANA membership
Yes 192 (9.3) 159 (9.3) 3.42 (0.91)
No 1,880 (90.7) 1,553 (90.7) 3.30 (0.92)
COHN/COHN-S
Yes 1,459 (70.4) 1,234 (72.1)a 3.38 (0.90)b
No 613 (29.6) 478 (27.9) 3.15 (0.93)
NIOSH spirometry course within the prior 5 years
Yes 654 (31.6) 575 (33.6)a 3.43 (0.88)b
No 1,418 (68.4) 1,137 (66.4) 3.26 (0.93)
Note. RPP = respiratory protection program; AAOHN = American Association of Occupational Health Nurses, Inc.; AOHP = Association of Occupational Health Professionals in Healthcare; ANA = American Nurses Association; COHN = certified occupational health nurse; COHN-S = certified occupational health nurse specialist; NIOSH = National Institute for Occupational Safety and Health. Sample sizes may vary due to missing data.
aFactors significantly different (p = .000) when compared to novice and beginner levels of competence.
bFactors with significantly different (p = .000) mean comfort scores.
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Burgel et al. Page 21
Table 7
Industry Factors by Competence and Comfort in Respiratory Protection Programs
Industry Factor
Total (n = 2,072)Competent, Proficient, or Expert (n = 1,712; 82.6%)
Mean Comfort With 12 RPP Elements (n = 2,072)
n (%) n (%) M (SD)
Manufacturing
Yes 543 (26.2) 445 (26.0) 3.24 (0.87)
No 1,529 (73.8) 1,267 (74.0) 3.34 (0.93)b
Health care sector
Yes 733 (35.4) 659 (38.5)a 3.52 (0.81)b
No 1,339 (64.6) 1,053 (61.5) 3.20 (0.95)
RPP at work site and occupational health nurse responsibility
RPP not present 238 (11.5) 144 (8.4) 2.99 (1.06)
RPP present but occupational health nurse not responsible
916 (44.2) 720 (42.1) 3.14 (0.91)
RPP present and occupational health nurse is responsible
918 (44.3) 848 (49.5)a 3.58 (0.81)b
Positive safety culture
Yes 1,891 (91.3) 1,589 (92.8)a 3.33 (0.90)b
No 181 (8.7) 123 (7.2) 3.12 (1.05)
Note. RPP = respiratory protection program. Sample sizes may vary due to missing data.
aFactors significantly different (p = .000) when compared to novice and beginner levels of competence.
bFactors with significantly different (p < .03) mean comfort scores.
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Burgel et al. Page 22
Table 8
Individual and Industry Factors Associated With Perceived Respiratory Protection Competency (n = 1,923)
Factor Odds Ratio 95% Confidence Interval p
Current RPP at work site and level of occupational health nurse responsibility .000
RPP with occupational health nurse not responsible vs. no program 1.78 1.24–2.54 .002
RPP with occupational health nurse responsible vs. no program 5.82 3.83–8.85 .000
Years of experience 1.05 1.03–1.07 .000
Highest educational preparation .088
Associate vs. diploma 1.59 0.97–2.61 .068
Any BA/BSN vs. diploma 1.06 0.70–1.61 .783
Any master’s vs. diploma 1.46 0.93–2.29 .102
Doctorate vs. diploma 1.70 0.67–4.33 .265
COHN or COHN-S certified 1.78 1.30–2.44 .000
Employed in health care sector 2.69 1.86–3.89 .000
AOHP member 1.64 1.01–2.68 .047
NIOSH spirometry course in the prior 5 years 2.03 1.49–2.76 .000
Positive safety culture 1.83 1.22–2.76 .004
Note. RPP = respiratory protection program; BA = bachelor of arts; BSN = bachelor of science in nursing; COHN = certified occupational health nurse; COHN-S = certified occupational health nurse specialist; AOHP = Association of Occupational Health Professionals in Healthcare; NIOSH = National Institute for Occupational Safety and Health. Ninety-three percent of the occupational health nurses had complete data for all factors in the model. Competent, proficient, and expert levels versus beginner and novice levels of competency in respiratory protection.
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.
Author M
anuscriptA
uthor Manuscript
Author M
anuscriptA
uthor Manuscript
Burgel et al. Page 23
Table 9
Individual and Industry Factors Associated With Higher Respiratory Protection Comfort (n = 1,923)
Factor Beta Coefficient 95% Confidence Interval p
Current RPP at work site and level of occupational health nurse responsibility
RPP with occupational health nurse not responsible vs. no program 0.048 −0.085–0.180 .480
RPP with occupational health nurse responsible vs. no program 0.478 0.340–0.615 .000
Years of experience 0.018 0.013–0.023 .000
Highest educational preparation
Associate vs. diploma 0.124 −0.022–0.271 .096
Any BA/BSN vs. diploma 0.084 −0.045–0.212 .200
Any master’s vs. diploma 0.270 0.134–0.406 .000
Any doctorate vs. diploma 0.217 −0.072–0.506 .141
COHN or COHN-S certified 0.202 0.106–0.298 .000
Employed in health care 0.333 0.226–0.439 .000
Employed in manufacturing −0.041 −0.139–0.058 .421
AOHP member 0.148 0.030–0.266 .014
NIOSH spirometry course in the prior 5 years 0.262 0.174–0.349 .000
Positive safety culture 0.135 −0.003–0.273 .055
Note. RPP = respiratory protection program; BA = bachelor of arts; BSN = bachelor of science in nursing; COHN = certified occupational health nurse; COHN-S = certified occupational health nurse specialist; AOHP = Association of Occupational Health Professionals in Healthcare; NIOSH = National Institute for Occupational Safety and Health. Ninety-three percent of the occupational health nurses had complete data for all factors in the model. Comfort scale score calculated by summing mean scores of 12 RPP elements from 1 to 5; higher scores mean greater comfort.
Workplace Health Saf. Author manuscript; available in PMC 2015 August 25.